Select Plan (Same as a DHMO) 1 • No annual maximum dollar limits, waiting periods, pre-existing condition exclusions, deductibles or claim forms 2 • Choose any in-network dentist from one of the largest DHMO-style networks in the Mid-Atlantic 3 • Family members may select different dentists • All network dentists are licensed, regulated and must meet Dominion’s Credentialing and Quality Assurance Program standards • Quality care at predetermined fees • Extensive coverage for over 250 procedures • No charge for oral exams, routine semi-annual cleanings, bitewing X-rays or topical fluoride for children • Orthodontic benefits provided for adults and children • Specialty care is also provided by Plan Specialists at rates 25% less than usual and customary charge (Specialty care in Delaware may differ). • Out-of-Area Emergency Care: You are covered up to $100 for palliative emergency dental treatment arising from accidental injury or illness while temporarily more than 50 miles from home. The $100 limit does not apply in Pennsylvania. Choice Plan You can choose from any of our plan designs: Select Plan (same as a DHMO) 1 and Access PPO. The following information summarizes each plan. For full details of the coverages, limitations and exclusions, please read the enclosed Description of Benefits and Member Copayments (Select Plan) and Coverage Schedule (Access PPO). Need to find a participating dentist? Simply visit DominionDental.com. We Work For Your Benefit. Access PPO • You may use any licensed dentist or choose from over 135,000 participating dentists nationwide. • The use of a network dentist can significantly reduce your out-of-pocket costs (Dominion members save an average of 20%). 4 • Deductible: An annual deductible of $50 per person ($150 family maximum) is required on basic care and major restorative care. • Annual Maximum: Benefits are subject to an annual maximum of $1,000 per insured person. • There are no waiting periods for diagnostic and preventive care. To be eligible for basic care, you must have completed 3 (three) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 (twelve) months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer’s prior dental coverage. • Claims Filing: Benefits will be paid to you or they may be assigned directly to your dentist. 99% of all claims are submitted by the dentist. 5 Your dentist may use the standard American Dental Association claims form. Claims can be filed electronically; Mailed To: Dominion Dental Services, P.O. Box 1126, Elk Grove Village, IL 60009; Or Faxed To: 888-208-8290. 1 Same as a DHMO plan with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre- authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies). 2 Out-of-area emergency care requires a receipt or other proof of loss. 3 Dominion Dental Services, Inc. Competitive Network Survey, 1st Quarter 2012. Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change. 4 Dominion Dental Services, Inc. - based on review of 2010 PPO claims data. 5 Dominion Dental Services, Inc. Internal Performance Report, 2011.
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City of Alexandria 607x 1007550 4-12 · PDF fileD5110/20 Complete upper/lower denture .....502 D5130/40 Immediate upper/lower denture ... D5710/11 Rebase complete denture, upper/lower
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Select Plan (Same as a DHMO)1
• No annual maximum dollar limits, waiting periods, pre-existing condition exclusions, deductibles or claim forms2
• Choose any in-network dentist from one of the largest DHMO-style networks in the Mid-Atlantic3
• Family members may select different dentists • All network dentists are licensed, regulated and must meet Dominion’s Credentialing and Quality Assurance Program standards• Quality care at predetermined fees• Extensive coverage for over 250 procedures• No charge for oral exams, routine semi-annual cleanings, bitewing X-rays or topical fl uoride for children• Orthodontic benefi ts provided for adults and children• Specialty care is also provided by Plan Specialists at rates 25% less than usual and customary charge (Specialty care in Delaware may differ).• Out-of-Area Emergency Care: You are covered up to $100 for palliative emergency dental treatment arising from accidental injury or illness while temporarily more than 50 miles from home. The $100 limit does not apply in Pennsylvania.
Choice PlanYou can choose from any of our plan designs: Select Plan (same as a DHMO)1 and Access PPO. The following information summarizes each plan.
For full details of the coverages, limitations and exclusions, please read the enclosed Description of Benefi ts and Member Copayments (Select Plan) and Coverage Schedule (Access PPO).
Need to fi nd a participating dentist? Simply visit DominionDental.com.
We Work For Your Benefi t.
Access PPO• You may use any licensed dentist or choose from over 135,000 participating dentists nationwide. • The use of a network dentist can signifi cantly reduce your out-of-pocket costs (Dominion members save an average of 20%).4
• Deductible: An annual deductible of $50 per person ($150 family maximum) is required on basic care and major restorative care. • Annual Maximum: Benefi ts are subject to an annual maximum of $1,000 per insured person. • There are no waiting periods for diagnostic and preventive care. To be eligible for basic care, you must have completed 3 (three) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 (twelve) months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefi t classifi cation under the current employer’s prior dental coverage.• Claims Filing: Benefi ts will be paid to you or they may be assigned directly to your dentist. 99% of all claims are submitted by the dentist.5 Your dentist may use the standard American Dental Association claims form. Claims can be fi led electronically; Mailed To: Dominion Dental Services, P.O. Box 1126, Elk Grove Village, IL 60009; Or Faxed To: 888-208-8290.
1 Same as a DHMO plan with fi xed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre- authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies).2 Out-of-area emergency care requires a receipt or other proof of loss.
3 Dominion Dental Services, Inc. Competitive Network Survey, 1st Quarter 2012. Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change.4 Dominion Dental Services, Inc. - based on review of 2010 PPO claims data. 5 Dominion Dental Services, Inc. Internal Performance Report, 2011.
A New Level of Service1
• Less than 0.2% of our members called with a service issue.
• ID cards and member packets were mailed within 4 days of enrollment.
• Over 94% group retention rate.
• 95% of Dominion members have access to at least two dentists within 10 miles.
1 Dominion Dental Services, Inc. Internal Performance Report, 2011.
How do I enroll?1. Complete the enclosed enrollment card.
• List all dependents you want covered.
• Be sure to check the appropriate box - Select
Plan or Access PPO.
• Select Plan Only - You must choose a primary
care dentist before or after enrollment. You
can fi nd a current list of dentists online at
DominionDental.com/fi nd-a-dentist. You can
also call us at 888-518-5338 to request that
one be mailed to you. After your effective date,
simply call the dental offi ce you selected and
make an appointment. Except for out-of-area
emergency care, you must receive
treatment at the dental offi ce you selected.
2. Return the completed enrollment card to your
Benefi t Administrator or as directed.
3. A Membership Card, Description of Benefi ts and
Member Copayments and Certifi cate of Coverage
will be mailed to you on or before your fi rst day of
eligibility.
4. If you have any questions regarding your date of
eligibility, please contact your Benefi ts Department.
Who is eligible?You and your dependents are eligible. Dependents
include your spouse and unmarried children under
age 26. Refer to your policy documents for further
details regarding your dependent coverage.
What if I change jobs?If you leave your place of employment, you have the
option of converting your coverage to an alternate
Dominion program using a different method of payment.
Can I make changes on the Internet?Yes. Dominion provides members with secure online
access to:
• ID card requests
• Plan information
• Dentist search
• Dental offi ce transfers (Select Plan Only)• Contact information
• Member services requests and general
correspondence
All changes are confi rmed by return email. For more
information, visit DominionDental.com.
115 South Union Street, Suite 300Alexandria, VA 22314888-518-5338 (Phone)703-518-0627 (Fax)DominionDental.com
0112
What is my monthly cost?What is my monthly cost?Select Plan 607xSubscriber Only $19.52
Subscriber and One Dependent $32.55
Subscriber and Two or
More Dependents $43.92
Access PPO 100/75/50Subscriber Only $36.36
Subscriber and One Dependent $67.95
Subscriber and Two or
More Dependents $103.18
Dominion Dental Services, Inc. is licensed as a Dental Plan Organization in Virginia, Maryland and Delaware, a Risk Assuming PPO in Pennsylvania and an Accident and Health Insurer in D.C.
We Work For Your Benefi t. Dominion Dental Services (Dominion) is an agile and innovative administrator of dental and vision benefi ts in the Mid-Atlantic, offering managed care and indemnity programs, claims adjudication and comprehensive plan administration. Among our 480,000 customers are leading health plans, employer groups, municipalities, associations and individuals. The Dominion group of companies includes Dominion Dental Services, Inc., the licensed underwriter of the dental plans, and Dominion Dental Services USA, Inc., a licensed administrator of dental and vision benefi ts.
Choice Plan Comparison
1. Same as a DHMO with fi xed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies).
2. Approximate percentage of coverage based on the Captiva Context Fee Schedule’s 80th percentile. A specifi c copayment schedule is enclosed.
3. As performed by a General Practitioner.
4. Out-of-area emergency care reimbursement requires a receipt or other proof of loss.
1. New applicants must fi rst complete 3 months of continuous coverage.
2. New applicants must fi rst complete 12 months of continuous coverage.
3. Deductibles and annual maximums are per insured person. Deductibles apply to basic care and major restorative care.
Select Plan 607x (Same as a DHMO)1 Access PPO 100/75/50
Summary of Benefi ts Your Coverage2
Diagnostic & Preventive Care• Oral exams
• Bitewing X-rays
• Topical fl uoride for children
• Semiannual (2) teeth cleanings
• Sealants
100%
70%
Basic Care• Fillings
○ Amalgam (silver)
○ Composite (white)
• Full and panoramic X-rays
• Extraction, erupted tooth
70-85%
Major Restorative Care3
Prosthetics• Crowns and bridges
• Dentures
• Relining of dentures
Periodontics• Root planing and therapy
Endodontics• Root canals
Oral Surgery• Extraction of impacted teeth
60-75%
Orthodontics• Children
• Adults
45%
Benefi t Features Your Coverage
Offi ce Visit $10 Copayment
Deductibles None
Annual Maximum None
Waiting Periods None
Claim Forms None4
Receive Care From Select Plan Dentist
Summary of Benefi ts Your Coverage
Diagnostic & Preventive Care• Oral exams
• Bitewing X-rays
• Topical fl uoride for children
• Semiannual (2) teeth cleanings
100%
Basic Care1
• Fillings
○ Amalgam (silver)
○ Composite (white)
• Full and panoramic X-rays
• Extraction, erupted tooth
75%
Major Restorative Care2
Prosthetics• Crowns and bridges
• Dentures
• Relining of dentures
Periodontics• Root planing and therapy
Endodontics• Root canals
Oral Surgery• Extraction of impacted teeth
50%
Orthodontics 0%
Benefi t Features Your Coverage
Offi ce Visit No Charge
Deductibles3 $50 ($150)
Annual Maximum3 $1,000
Waiting Periods Yes
Claim Forms Yes
Receive Care From Any Dentist or Access PPO Dentist
SELECT ONE: Select Plan Access PPO
DOMINION DENTAL SERVICES, INC. ENROLLMENT CARD
Enrollment Information
List All Your Eligible Dependents BelowLast name (if different) First Name M.I. Birthdate (MM/DD/Spouse
Child
Child
Child
Child
Child
SELECT PLANProvider Selection
Sex (M/F)
Child
Dental Offi ce Name & Code # (As Indicated on Your Dentist Directory)
Agent/Broker # Group # Group Name Coverage Eff. Date
D2610 Inlay - porcelain/ceramic - one surface ................................$272D2620 Inlay - porcelain/ceramic - two surfaces ................................294D2630 Inlay - porcelain/ceramic - three surfaces ..............................314D2642 Onlay - porcelain/ceramic - two surfaces ..............................327D2643 Onlay - porcelain/ceramic - three surfaces ............................339D2644 Onlay - porcelain/ceramic - four or more surfaces ................339D2650 Inlay - resin based composite - one surface............................258D2651 Inlay - resin based composite - two surfaces .........................258D2652 Inlay - resin based composite - three or more surfaces ............258D2662 Onlay - resin based composite - two surfaces .......................303D2663 Onlay - resin based composite - three surfaces ......................303D2664 Onlay - resin based composite - four or more surfaces .........303D2710 Crown - resin bsed composite - indirect ................................196D2712 Crown - 3/4 resin based composite (excluding veneers) .........381D2720/21/22 Crown - resin with metal ........................................................309D2740 Crown - porcelain/ceramic substrate ................................399D2750/51/52 Crown - porcelain fused to metal ...........................................361D2780/81/82 Crown - 3/4 cast with metal ...................................................238D2783 Crown - 3/4 porcelain/ceramic ...............................................349D2790/91/92 Crown - full cast metal ...........................................................348D2793 Crown - prefabricated stainless steel .....................................103D2910/20 Recement inlay/crown per unit ................................................31D2930 Crown - prefabricated stainless steel - primary tooth ..............91D2931 Crown - prefabricated stainless steel - permanent tooth ..........99D2932 Crown - prefabricated resin .....................................................99D2950 Core buildup, including any pins .............................................85D2952 Cast post & core in addition to crown ...................................129D2954 Prefabricated post & core in addition to crown .....................106D2955 Post removal (not in conj. w/ endo therapy) ............................76D2970 Temporary crown (w/ perm. crown) ................................No ChargeD2980 Crown repair, by report ............................................................72
PROSTHETICS (DENTURES)D5110/20 Complete upper/lower denture ...............................................502D5130/40 Immediate upper/lower denture .............................................526D5211/12 Upper/lower, resin base partial denture (including any conventional clasps, rests & teeth) .............................489D5213/14 Upper/lower, cast base partial denture with resin base (incl. conventional clasps, rests & teeth) ...................533D5281 Removable unilateral partial - one piece cast metal (incl. clasps and teeth) ......................................314D5410/11 Adjust complete denture, upper/lower .....................................25D5421/22 Adjust partial denture, upper/lower .........................................25D5510/5610 Repair denture base (complete or resin) ..................................63D5520 Replace missing/broken teeth (each tooth) ..............................63D5620 Repair cast framework .............................................................63D5630/60 Clasp replaced, repaired or added ............................................82D5640 Replace broken tooth, per tooth ...............................................63D5650 Add tooth to existing partial denture .......................................63D5670/71 Replace all teeth and acrylic on cast metal framework (maxillary or mandibular) ...................................186D5710/11 Rebase complete denture, upper/lower ..................................201D5720/21 Rebase partial denture, upper/lower ......................................201D5730/31 Reline complete denture, upper/lower (chairside) ................ 113D5740/41 Reline partial denture, upper/lower (chairside) ...................... 113D5750/51 Reline complete upper/lower: lab ..........................................176D5760/61 Reline upper/lower partial: lab ...............................................176D5810/11 Interim complete denture, upper/lower ..................................276D5820/21 Interim partial denture, upper/lower ......................................276D5850/51 Tissue conditioning, upper/lower, per unit...............................53
BRIDGE & PONTICS D6210/11/12 Pontic - metal .........................................................................348D6240/41/42 Pontic - porcelain fused to metal ...........................................361D6245 Pontic - porcelain/ceramic........................................................396D6250/51/52 Pontic - resin with metal ........................................................309D6545 Retainer - cast metal for a resin bonded fi xed ........................187D6548 Retainer - porcelain/ceramic for resin bonded fi xed prosthesis .....................................................293D6600 Inlay - porcelain/ceramic, two surfaces .................................162D6601 Inlay - porcelain/ceramic, three or more surfaces ..................173D6602 Inlay - cast high noble metal, two surfaces ............................180D6603 Inlay - cast high noble metal, three or more surfaces ............212D6604 Inlay - cast predom. base metal, two surfaces ..................... $116
ADA MEMBERADA MEMBERCODE BENEFIT COPAYMENT ($)CODE BENEFIT COPAYMENT ($)
ADA MEMBERADA MEMBERCODE BENEFIT COPAYMENT ($)CODE BENEFIT COPAYMENT ($)
DIAGNOSTIC / PREVENTIVE / ADJUNCTIVED9439 Offi ce visit ..............................................................................$10D0120 Periodic oral evaluation ..............................................No ChargeD0140 Limited oral evaluation - problem focused .................No ChargeD0150 Comprehensive oral evaluation ...................................No Charge D0160 Detailed and ext. oral eval. - problem focused ............No ChargeD0170 Re-evaluation - limited, problem focused (established patient; not postoperative visit) ..............No ChargeD0210 Intraoral complete series (including bitewings) ..........No ChargeD0220 Intraoral - periapical fi rst fi lm .....................................No ChargeD0230 Intraoral - periapical each additional fi lm ...................No ChargeD0240 Intraoral - occlusal fi lm ...............................................No ChargeD0250/60 Extraoral - fi rst and each additional fi lm .....................No ChargeD0270/72/74 Bitewing x-ray - one, two or four fi lm(s) ....................No ChargeD0277 Vertical bitewings - seven to eight fi lms .....................No ChargeD0330 Panoramic fi lm .........................................................................25D0460 Pulp vitality tests .........................................................No ChargeD0470 Diagnostic casts (not in conj. with Ortho) ..................No ChargeD1110 Prophylaxis - teeth cleaning; adult (one per six months, per member) ..............................................No ChargeD1120 Prophylaxis - teeth cleaning; child (one per six months, per member. Exclusive of ADA code D1201) ........No ChargeD1201 Topical fl uoride with prophylaxis (child)....................No ChargeD1203 Topical fl uoride without prophylaxis (child) ..............No ChargeD1310 Nutritional counseling for control and treatment of dental disease .....................................No ChargeD1320/30 Oral hygiene instructions ............................................No ChargeD1351 Sealant - per tooth (up to 14 years of age) ...............................15D9110 Palliative (emergency) treatment ............................................33D9210/15 Local anesthesia ..........................................................No ChargeD9211 Regional block anesthesia ...........................................No ChargeD9212 Trigeminal division block anesthesia ..........................No ChargeD9230 Analgesia, anxiolysis, inhalation of nitrous oxide ...................28D9310 Consultation (diagnostic service provided by dentist or specialist other than practitioner providing treatment) ........34D9910 Application of desensitizing medicament ................................17D9930 Emergency visit during offi ce hours ........................................39D9990 Broken offi ce appointment - per ½ hour ..................................22
SPACE MAINTAINERSD1510/20 Space maintainer fi xed/removable - unilateral ....................... 111D1515/25 Space maintainer fi xed/removable - bilateral ........................129D1550 Recementation of space maintainer .........................................28
RESTORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (Silver)D2140 Amalgam - one surface, primary or permanent ...........................17D2150 Amalgam - two surfaces, primary or permanent ...........................20D2160 Amalgam - three surfaces, primary or permanent ...................26D2161 Amalgam - four or more surfaces, primary or permanent ........................................................................31
RESIN/COMPOSITE RESTORATIONS (Tooth Colored)D2330 Resin - one surface, anterior ....................................................44D2331 Resin - two surfaces, anterior ...................................................51D2332 Resin - three surfaces, anterior .................................................60D2335 Resin - four or more surfaces, anterior ....................................69D2391 Resin - one surface, posterior ...................................................47D2392 Resin - two surfaces, posterior .................................................54D2393 Resin - three surfaces, posterior ...............................................63D2394 Resin - four or more surfaces, posterior ...................................72D2940 Sedative fi lling .........................................................................29D2951 Pin retention - per tooth in addition to restoration ...................17D3110/20 Pulp cap direct/indirect (excl. fi nal rest) ..................................18
CROWN & BRIDGED2390 Resin based composite crown, anterior .................................134D2510 Inlay - metallic - one surface .................................................282D2520 Inlay - metallic - two surfaces ................................................282D2530 Inlay - metallic - three or more surfaces ................................290D2542 Onlay - metallic - two surfaces ..............................................338D2543 Onlay - metallic - three surfaces ............................................380D2544 Onlay - metallic - four or more surfaces ................................380
Plan 607xDescription of Benefi ts & Member Copayments
Form607x-VA All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.
D7240 Removal of impacted tooth - completely bony ....................$164D7241 Removal of impacted tooth - completely bony, with unusual surgical complications .................................144D7250 Removal of residual tooth roots ...............................................98D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus ........................148D7280 Surgical access of an unerupted tooth ......................................93D7291 Trasseptal fi berotomy/supra crestal fi berotomy, by report ..............................................................................37D7310/20 Alveoloplasty per quadrant .....................................................92D7510 Incision/draining of abscess, soft tissue ...................................63D7960 Frenulectomy (frenectomy or frenotomy) .............................1621 As performed by a Particpating General Dentist. See Plan Exclusion #15.
ORTHODONTICS2
D8660 Pre-orthodontic treatment visit, records and models .............413D8070 Comprehensive orthodontic treatment of the transitional dentition .......................................................3,304D8080 Comprehensive orthodontic treatment of adolescent dentition ........................................................3,422D8090 Comprehensive orthodontic treatment of adult dentition ..........................................................................3,658D8670 Periodic orthodontic visit (beyond 24 months of treatment) per month charge .............................................. 118D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) ........................4132Phase I Treatment (D8010 - D8050) is provided at a 15% reduction from the orthodontist’s UCR fees. See limitation #17 for additional coverage exclusions.
D6605 Inlay - cast predom. base metal, three or more surfaces ............148D6606 Inlay - cast noble metal, two surfaces ....................................146D6607 Inlay - cast noble metal, three or more surfaces ....................158D6608 Onlay - porcelain/ceramic, two surfaces ................................178D6609 Onlay - porcelain/ceramic, three or more surfaces ................186D6610 Onlay - cast high noble metal, two surfaces ............................212D6611 Onlay - cast high noble metal, three or more surfaces ............227D6612 Onlay - cast predom. base metal, two surfaces ......................148D6613 Onlay - cast predom. base metal, three or more surfaces .............162D6614 Onlay - cast noble metal, two surfaces ..................................158D6615 Onlay - cast noble metal, three or more surfaces ...................169D6720/21/22 Crown - resin w/ metal ...........................................................309D6740 Crown - porcelain/ceramic .......................................................396D6750/51/52 Crown - porcelain to metal ....................................................361D6780 Crown - 3/4 cast high noble metal .........................................348D6781 Crown - 3/4 cast predominantly base metal ...........................336D6782 Crown - 3/4 cast noble metal .................................................344D6783 Crown - 3/4 porcelain/ceramic ...............................................350D6790/91/92 Crown - full cast metal ...........................................................348D6930 Recement fi xed partial bridge ..................................................46D6970/71 Cast post & core ....................................................................129D6972 Prefabricated post & core - in addition to bridge retainer .....106D6973 Core buildup for retainer, including any pins ..........................85D6975 Coping - metal ........................................................................222D6976 Each additional cast post - same tooth .....................................88D6977 Each additional prefabricated post - same tooth ..........................41D6980 Fixed partial denture repair, by report.................................... 117
ENDODONTICS1
D3220 Therapeutic pulpotomy (excl. fi nal rest) ..................................54D3221 Pulpal debridement, primary and perm. teeth ..............................58D3310 Anterior (excl. fi nal rest) ........................................................225D3320 Bicuspid (excl. fi nal rest) .......................................................290D3330 Molar (excl. fi nal rest) ...........................................................361D3333 Internal root repair of perforation defects ................................65D3346 Re-treatment - anterior ...........................................................251D3347 Re-treatment - bicuspid ..........................................................322D3348 Re-treatment - molar ..............................................................380D3410 Apicoectomy/periradicular surgurey, anterior .......................206D3421 Apicoectomy - bicuspid (fi rst root) ........................................232D3425 Apicoectomy - molar (fi rst root) ............................................245D3426 Apicoectomy - (each additional root) ......................................97D3430 Retrograde fi lling - per root .....................................................77D3450 Root amputation - per root .....................................................135D3920 Hemisection (including any root removal) ............................135D3950 Canal prep/fi t of preformed dowel or post ...............................97
PERIODONTICS1
D0180 Comprehensive periodontal evaluation - new or established patient - not in conjunction with D0150, limited to once per 18 months .............................................35D4210 Gingivectomy/gingivoplasty - four or more teeth per quad. ............................................................................187D4211 Gingivectomy/gingivoplasty one-to-three teeth per quad. ..............................................................................64D4240 Gingival fl ap procedure, including root planing, per quad. ............277D4241 Gingival fl ap procedure, including root planing- one-to-three teeth, per quadrant ...........................................67D4260 Osseous (bone) surgery - four or more per quad. ..................386D4261 Osseous (bone) surgery - one - three teeth per quad. .............258D4268 Surgical revision procedure, per tooth ...................................236D4274 Distal or proximal wedge procedure .....................................206D4341 Perio scaling & root planing four or more per quad. ..................76D4342 Perio scaling & root planing one-to-three teeth per quad. ...............41D4355 Full mouth debridement ...........................................................58D4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report ...................................................64D4910 Periodontal maintenance ..........................................................59D9940 Occlusal guard by report ........................................................197D9950 Occlusion analysis - mounted case ..........................................70D9951 Occlusal adjustment, limited ....................................................44D9952 Occlusal adjustment, complete ..............................................182
Plan 607xADA MEMBERADA MEMBERCODE BENEFIT COPAYMENT ($)CODE BENEFIT COPAYMENT ($)
ADA MEMBERADA MEMBERCODE BENEFIT COPAYMENT ($)CODE BENEFIT COPAYMENT ($)
Plan Exclusions 1. Services for injuries or conditions which are covered under worker’s compensation and
employer’s liability laws. Services which are provided without cost to Subscribers by any federal, state, municipal, county or other subdivision’s program (with the exception of Medicaid).
2. Services which, in the opinion of the attending dentist, are not necessary for the patient’s dental health.
3. Cosmetic, elective or aesthetic dentistry.4. Oral surgery requiring the setting of fractures or dislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital,
anodontic, mandibular prognathism or development malformations where, in the sole discretion of the Participating Dentist, such services should not be performed in a dental offi ce.
6. Dispensing of drugs.7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting from major disaster, epidemic or war, including
declared or undeclared war or acts of war. 9. Replacement due to loss or theft of prosthetic appliance. 10. General anesthesia and sedation. 11. Implantation and related restorative procedures.12. Unlisted procedures. 13. Services obtained outside of the dental offi ce in which enrolled and that are not pre-
authorized by such offi ce or Dominion Dental Services, Inc. (with the exception of out-of-area emergency dental services).
14. Services related to the treatment of TMD (Temporal Mandibular Disorder).15. Services related to procedures that are of such a degree of complexity as to not be
normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Plan Specialist (with the exception of orthodontics). Plan Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction from their UCR that will vary between specialists.
16. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth.
17. The Invisalign system and similar specialized braces are not a covered benefi t. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility.
Plan Limitations 1. Replacement of a bridge, crown or denture within fi ve (5) years after the date it was
originally installed.2. Replacement of fi lling within two (2) years after original date of placement.3. Teeth cleaning (prophylaxis) at intervals of less than six (6) months. 4. Crown and bridge fees apply to treatment involving fi ve or fewer units when presented in
a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%.
5. Full mouth x-rays or panoramic fi lm – one set every three years. 6. Retreatment of root canal within two (2) years of the original treatment.7. Limit 4381 to one benefi t per tooth for three teeth per quadrant or a total of 12 teeth for
all four quadrants per twelve (12) months. Must have pocket depths of fi ve (5) millimeters or greater.
We are continually expanding our network of dentists. For the most up-to-date listing of all participating general dentists and specialists visit us on the web at DominionDental.com. A printed list can also be requested by calling our Member Services Department toll-free at 888-518-5338.
Dominion’s service area includes the Virginia cities of Alexandria, chesapeake, colonial Heights, Fairfax city, Falls church, Fredericksburg, Hampton, Hopewell, Manassas, Manassas Park, newport news, norfolk, Petersburg, Poquoson, Portsmouth, richmond, Suffolk, Virginia Beach, Williamsburg and Winchester. the service area also includes the Virginia counties of Arlington, charles city, chesterfield, Dinwiddie, Fairfax, Fauquier, Frederick, Gloucester, Goochland, Hanover, Henrico, James city, King & Queen, King William, loudoun, Prince George, Prince William, Spotsylvania, Stafford, Warren and york. We also operate in the District of columbia, Delaware, Maryland, and certain counties in the commonwealth of Pennsylvania.
*Accepts current patients only.†6000x and 5000x Program not accepted.
‡6000x and 5000x Program only.
1Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies)
VirGiniAAlexAnDriA cityAlexandria
#50340 (571) 970-3783 Alexandria Dental Care PLLC 715 Pendleton St Alexandria, VA 22314
#144 (703) 823-2413 Bright Now Dental 5249 Duke Street, Suite 210 Alexandria, VA 22304
#239 (703) 823-8812 Nathan Tsui, D.D.S. 5249 Duke St., Suite 10 Alexandria, VA 22304
#324 (301) 567-3122 David G. O’Neal, D.D.S., & Assoc. 6188 Oxon Hill Rd., Suite 200 Oxon Hill, MD 20745
#37629 (301) 505-6055 Quentin E. Monroe Dental Services 5448 St. Barnabas Rd. Oxon Hill, MD 20745
#68487* (866) 838-3430 Smile America Dental 1004 White Oak Dr Oxon Hill, MD 20745
riverdale
#210† (301) 864-5200 The Dental Group 6200 Baltimore Ave., Ste. 200 Riverdale, MD 20737
temple Hills
#37663 (301) 702-4080 All Smiles Dental Care 3847 Branch Ave, Suite 124 Temple Hills, MD 20748
#51072 (301) 423-6423 Oral Health Associates 4316 St Barnabas Rd Temple Hills, MD 20748
upper Marlboro
#187 (301) 627-1414 Harry J. Klapper, D.D.S. 5749 Crain Hwy. Upper Marlboro, MD 20772
WASHinGton countyHagerstown
#462 (301) 797-7078 Antietam Valley Dental Center 1246 Maryland Avenue Hagerstown, MD 21740
Hancock
#68461 (301) 678-6788 Antietam Valley Dental Center 257 W Main St Hancock, MD 21750
WicoMico countySalisbury
#2767 (410) 546-5900 Delaware Maryland Dental 123 West College Ave. Salisbury, MD 21804
#2319 (410) 742-0166 George C. Viertl, D.D.S., P.C. 560 Riverside Dr., Suite B206 Salisbury, MD 21801
WorceSter countyocean Pines
#33847 (410) 208-0054 Robert D. Steinberg, D.D.S. 11204 Racetrack Rd, Pavillions Suite 102 Ocean Pines, MD 21811
Dominion Dental Services, Inc.115 South Union Street
Suite 300Alexandria, VA 22314
(888) 518-5338DominionDental.com
pid1235
Access PPO PlanCoverage Schedule
Plan Exclusions:
1. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared.2. Services which are covered under Medicare, worker’s compensation, employer’s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law.3. Services and treatment provided without charge or for which there would be no charge in the absence of insurance.4. Services not listed as covered.5. Hospitalization for any dental procedure.6. Services and treatment for whichMember is eligible for coverage under his or her hospital, medical/surgical or majormedicalplan.7. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry. 8. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth.9. Replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function.10. Replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semi-precision attachments; denture duplication; sealants; periodontal splinting of teeth.11. Services for increasing vertical dimension, restoring occlusion,
replacing tooth structure lost by attrition, and correcting developmentalmalformationsand/orcongenitalconditions.
12. Oral hygiene instructions; plaque control; completion of a claim form; acid etch; brokenappointments; prescription ortake-homefluoride;ordiagnosticphotographs.13. Dispensing of drugs.14. Diagnosis or treatment of temporomandibular joint (TMJ)syndromes,problemsand/orocclusaldisharmony.15. Procedures that in the opinion of Dominion Dental Services are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member’s condition.16. Treatmentofcleftpalate,anodontia,malignanciesorneoplasms.17. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36monthsofMember’scontinuouscoverageundertheplan.18. Maryland policyholders only: Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. “Prohibited referral” means a referral prohibited by Section 1-302 of the Maryland Health Occupations Article.
0109PCOV
Plan will pay either the Participating Dentist’s negotiated fee or the Maximum Allowable Charge (subject to benefit coverage percentage) for dental procedures and services as shown below, after any required Annual Deductible.
Class I. Diagnostic and Preventive Services: 1. Two evaluations per Calendar Year including a maximum of one comprehensive evaluation 2. One emergency or problem focused exam (D0140) per Calendar Year 3. Two prophylaxis (cleaning, scaling and polishing teeth) per Calendar Year (one additional cleaning is covered during pregnancy and for diabetic patients) 4. OnetopicalfluorideperCalendarYear,toage16 5. Bitewing x-rays, 2 per Calendar Year 6. Emergencypalliativetreatment(onlyifnoservicesother than exam and x-rays were performed on the same date of service) Class II. Basic Services: 1. Simple extraction of teeth 2. Amalgamandcompositefillings(restorationsof mesiolingual, distolingual, mesiobuccal, and distobuccal surfaces considered single surface restorations) 3. Periapical x-rays 4. Onediagnosticx-ray,fullorpanoramicper36months 5. Pinretentionoffillings(multiplepinsonthesametooth are allowable as one pin) 6. Antibioticinjectionsadministeredbyadentist 7. Space maintainers to preserve space between teeth for premature loss of a primary tooth (does not include use for orthodontic treatment)
Class III. Major Services: 1. Oral surgery, including postoperative care for: a. Removal of teeth, including impacted teeth b.Extractionoftoothroot c. Alveolectomy, alveoplasty, and frenectomy d.Excisionofperiocoronalgingiva,exostosis,orhyper plastic tissue, and excision of oral tissue for biopsy e. Reimplantation or transplantation of a natural tooth f.Excisionofatumororcystandincisionanddrainage of an abscess or cyst 2. Endodontictreatmentofdiseaseofthetooth,pulp,root, and related tissue, limited to: a. Root canal therapy (not covered if pulp chamber was opened before effective date of coverage) b. Pulpotomy c. Apicoectomy d.Retrogradefillings 3. Periodontic services, limited to: a. Two periodontal cleanings following surgery per Calendar Year (D4341 is not considered surgery) b. One root scaling and planing per quadrant of mouth per6months
c. Occlusaladjustmentperformedwithcoveredsurgery d. Gingivectomy and gingival curettage e.Osseoussurgeryincludingflapentryandclosure f. Pedical or free soft tissue graft g. One appliance (night guards) per 5 years h. One full mouth debridement per lifetime 4. Onestudymodelper36months 5. Crown build-up for non-vital teeth 6. Recementingbridges,inlays,onlaysandcrowns 7. Onerepairofdenturesorfixedbridgeworkper24 months 8. General anesthesia and analgesic, including intravenous sedation,inconjunctionwithcoveredoralsurgery, periodontal surgery 9. Restoration services, limited to: a. Gold or porcelain inlays, onlays, and crowns for tooth with extensive caries or fracture that is unable toberestoredwithanamalgamorcompositefilling b. Replacement of existing inlay, onlay, or crown, after 5 years of the restoration initially placed or last replaced (will not apply if replacement is necessary due to the extraction of functioning natural teeth after the effective date of coverage) c. Stainless steel crowns d. Post and core in addition to crown when separate from crown for endodontically treated teeth, with a good prognosis endodontically and periodontally 10. Prosthetic services, limited to: a. Initialplacementofdenturesorfixedbridgework (including acid etch metal bridges) b.Replacementofdenturesorfixedbridgeworkthat cannot be repaired after 5 years from the date of last placement c. Addition of teeth to existing partial denture d. One relining or rebasing of existing removable dentures per 24 months (only after 12 months from date of last placement)
Class IV. Orthodontia Services: Not Covered Diagnostic, active and retention treatment to include removablefixedappliancetherapyandcomprehensive therapy
Access PPO Plan100/75/50/0
Benefit Coverage In-Network Out-of-Network
Class I 100% 100% Class II 75% 75% Class III 50% 50% Class IV 0% 0% Endo/Perio Class III Benefits Class III Benefits
Annual Deductible In-Network Out-of-Network
Amount $50 $50 Max per Family $150 $150 Applies to all No, Waived on No, Waived on Benefits Class I Benefits Class I Benefits
Maximums In-Network Out-of-Network
Annual $1,000 $1,000 LifetimeOrtho N/A N/A
* Annual Maximum applies to Class I, Class II andClassIIIBenefits.
Waiting Periods In-Network Out-of-Network
ClassI NONE NONE Class II 3 Months 3 Months Class III 12 Months 12 Months ClassIV N/A N/A
• Deductible iscombinedforallservicesfor each Calendar Year per Member – maximum $150 per family. • Waiting period credit will be given for the length of time Member was covered under each benefit classification under the current employer’s prior dental plan.• Servicesmaybereceivedfromanylicensed dentist.• If course of treatment is to exceed$300, prior review is requested.